IN
DEGREE PROJECT INDUSTRIAL ENGINEERING AND MANAGEMENT,
SECOND CYCLE, 30 CREDITS ,
STOCKHOLM SWEDEN 2017
Improving the process
performance of the outpatient
surgery by managing information
quality
A case study at Danderyd’s University Hospital
MELIHA SÖLEN
LOUISE WEILENMANN
KTH ROYAL INSTITUTE OF TECHNOLOGY
Improving the process performance of the
outpatient surgery by managing information
quality
- A case study at Danderyd’s University Hospital
Meliha Sölen
Louise Weilenmann
Master of Science Thesis INDEK 2017:44 KTH Industrial Engineering and Management
Förbättra processprestandan av dagkirurgin
genom att hantera informationskvalitet
- En fallstudie på Danderyds Sjukhus
av
Meliha Sölen
Louise Weilenmann
Examensarbete INDEK 2017:44 KTH Industriell teknik och management
Abstract
Development in medicine has enabled surgical procedures, previously considered to be advanced and required the patient to be hospitalized, to be conducted as outpatient surgeries, meaning that the patients are able to return home the same day. Due to the major benefits associated with outpatient surgeries, such as enhanced effectiveness and efficiency, the demand for these types of surgeries is continuously increasing. Therefore, it is considered to be necessary to improve the process performance of outpatient surgeries to meet both current and future demands.
Studies have shown that the major issues in healthcare is related to the quality of the information that controls the processes, which has in turn been found to have a direct impact on the process performance of organizations. Thus, the purpose of this study was to investigate how the process performance of outpatient surgeries could be improved by managing information quality. By the identified improvement areas within the quality of the information which control the process performance of the outpatient surgery, the findings from this study could be used as a basis for enhancing the process performance, thereby enabling a better healthcare.
To achieve the purpose of this study, a single-case study was conducted at the women’s department at Danderyd’s University Hospital, which is one of the largest public hospitals in Sweden. The empirical data, gathered from interviews, observations, survey and internal documents, was together with the literature review the constitution for the analysis, with the aim of achieving the purpose of this study. Poor information quality across all dimensions were identified, where combinations of lacking quality dimensions contributed to six different types of waste activities. Thus, this confirmed previous research on the negative impact of poor information quality on process performance, and also showed its specific impact on the investigated outpatient surgery.
Master of Science Thesis INDEK 2017:44
Improving the process performance of the outpatient surgery by managing information quality
- A case study at Danderyd’s University Hospital Meliha Sölen Louise Weilenmann Approved 2017-06-05 Examiner Andreas Feldmann Supervisor Jannis Angelis Commissioner
Clinical Innovation Fellowship
Contact person
Furthermore, the analysis presented two factors influencing the overall poor information quality in the outpatient surgery. Firstly, the information provided to the surgical staff, which controls the work inside the theatre, was not updated accordingly to the specific preferences of the operating surgeon. Secondly, interconnections between the different dimensions of information quality were identified, where one specific dimension were found to be the root cause of the overall poor information quality. Conclusively, identifying potential improvement areas by knowing what influences the information quality and how this affects the process performance is believed to provide the foundation for improving the outpatient surgery.
Sammanfattning
Den medicinska utvecklingen har möjliggjort att kirurgiska ingrepp, som tidigare ansetts vara avancerade och krävt att patienten blivit inlagd, kunnat genomföras som dagkirurgi, vilket innebär att patienten kan återvända hem samma dag. På grund av de stora fördelarna som associeras med dagkirurgi, som exempelvis en mer effektiv sjukvård, ökar ständigt behovet för dessa typer av operationer. Det anses därför vara nödvändigt att förbättra prestandan hos processerna inom dagkirurgi för att kunna möta nuvarande och framtida behov.
Studier har visat att det största problemet inom sjukvård är relaterat till kvaliteten av informationen som styr processerna, vilket i sin tur har visat ha en direkt inverkan på prestandan av processerna inom organisationerna. Syftet för denna studien är därför att undersöka hur prestandan av processerna inom dagkirurgi kan förbättras genom att hantera informationskvaliteten. Genom att identifiera de dimensioner av informationskvalitet som styr prestandan av processerna inom dagkirurgi, kan resultaten från denna studie användas som grund för att förbättra prestandan av processerna och därmed även möjliggöra en bättre sjukvård.
För att kunna uppnå syftet till denna studie har en fallstudie genomförts på kvinnokliniken på Danderyds universitetssjukhus, vilket är ett av de största offentliga sjukhusen i Sverige. Den empiriska data som samlats in från intervjuer, observationer, enkätundersökning och interna dokument, har tillsammans med en litteraturstudie varit grunden för analysen, och avsett att besvara studiens frågeställning och därmed uppnå syftet. Resultaten visar dålig informationskvalitet inom alla dimensioner vilket, i olika kombinationer, bidrog till sex olika typer av icke-värdeskapande aktiviteter. Detta bekräftade tidigare studier om den negativa påverkan av dålig informationskvalitet på prestandan av processerna, men även visade på vilket sätt detta påverkar dagkirurgi.
Examensarbete INDEK 2017:44
Förbättra processprestandan av dagkirurgin genom att hantera informationskvalitet
- En fallstudie på Danderyds Sjukhus
Meliha Sölen Louise Weilenmann Godkänt 2017-06-05 Examinator Andreas Feldmann Handledare Jannis Angelis Uppdragsgivare
Clinical Innovation Fellowship
Kontaktperson
Resultaten från analysen visar dessutom två faktorer som påverkar den övergripande informationskvaliteten inom dagkirurgin. För det första, att informationen, som operationspersonalen blivit försedda med och som styr arbetet inne i operationssalen, inte varit uppdaterad enligt den opererande kirurgens preferenser. För det andra, sammankopplingar mellan de olika dimensionerna av informationskvalitet, där en av dimensionerna identifierades som roten till den övergripande dåliga informationskvaliteten. Att veta vad det är som bidrar till dålig informationskvalitet och hur detta påverkar prestandan av processerna, tros kunna användas som grund för att kunna förbättra dagkirurgi.
Acknowledgement
First and foremost, we would like to express our gratitude to our supervisor at KTH, Dr. Jannis Angelis, who gave us the support and guidance to successfully complete this report. We would also like to thank the seminar group and opponents at KTH, the reference group at the hospital and CIF for their valuable feedback. Furthermore, we received a warm welcome at the women’s department at Danderyd’s University Hospital which facilitated the empirical study. We would therefore like to thank all personnel and especially those who contributed with their time to interviews and the survey. A special thanks and tribute should also be given to our supervisor at Danderyd’s University Hospital, Dr. Désirée Lichtenstein for the support and sharing her knowledge in medicine. Finally, we would like to take the opportunity to thank our families and friends for all the support during these five years at KTH.
Stockholm, June 2017
Abbreviations
CIF - Clinical Innovation Fellowship KI - Karolinska Institutet
KTH - Royal Institute of Technology (Kungliga Tekniska Högskolan in Swedish) OR-staff – Operating room staff
OR-system – Operating room system TPS - Toyota Production System
Glossary
Orbit – The computer system used at Danderyd’s University Hospital for managing surgery
scheduling.
Surgical staff - The surgical team inside the operating theatre, consisting of a surgical nurse
and an assistant nurse.
Hysteroscopy – An examination of the uterine cavity with an optical instrument called
hysteroscope.
Diagnostic hysteroscopy with bettocchi - A hysteroscopy performed with a hysteroscopic
instrument called bettocchi.
Hysteroscopic sterilizations - A surgical procedure for sterilizing patients by using a
hysteroscope.
Hysteroscopic resection - A surgical procedure for extracting fibroids from the uterus by using
a hysteroscope.
Hysteroscopic myomectomy - A less invasive surgical procedure for extracting fibroids from
the uterus.
Conization - A surgical procedure for excision of abnormal cells in the cervix uteri.
Loop diathermy - A conization performed with a heated metal wire called loop diathermy. Laser excisional - A conization performed with laser.
OR-staff – All personnel inside the operating theatre, including operating staff, surgeon,
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1. Introduction
The following chapter presents the background, problematization, purpose and research questions of this study. Furthermore, the study delimitations are also presented, as well as the thesis outline.
1.1 Background
The purpose of this study is to investigate how the process performance of outpatient surgeries can be improved by managing information quality. In healthcare, the major experienced issues are not related to the quality of the implementation of a process, such as surgery, but are rather related to the quality of the information that controls the process. Thus, the quality of information is of great importance as it has a major impact on the organizational performance across industries (Wickramasinghe et al., 2014). Currently, the amount of data and information is exponentially growing, thereby creating difficulties of maintaining a high quality of information in organizations (Borek et al., 2013). This entails a considerable risk in healthcare, where low information quality has the potential of resulting in fatal consequences (Welzer et al., 2005; Mettler et al., 2008; Hausvik, 2017). In the United States, problems with poor information quality constitute the eighth largest cause of death in healthcare services, where the total costs caused by medical errors exceeds $17 billion a year (Su & Shen, 2010)
In 1996, a two months old pediatric patient received a fatal overdose at the outpatient clinic of Hermann Hospital in Houston due to a misplaced decimal point. The tragic incident was not considered to be a single person’s mistake, but was instead a devastating result of a systematic error which allowed a ten times larger dose to be injected unnoticed (Belkin, 1997). Unfortunately, there are many more examples of devastating consequences caused by the lack of information quality, where wrong decisions have been made, incorrect surgeries have been performed, and tests results have been mixed up, among others (Al-Hakim, 2014). Hence, the quality of information has been found to have a direct impact on the safety and care that is provided to patients (Welzer et al., 2005; Ratnaningtyasa & Surendro, 2013). Therefore, it is of great importance to recognize the issues related to information quality (Wickramasinghe et al., 2014).
With the rapidly growing amount of data and information, causing a risk of poor information quality, it is also vital to understand how organizational processes are affected. A multi-disciplinary literature review of 71 articles indicated a direct impact of information quality on the process performance in organizations, thus emphasizing the importance of “modelling
processes to be IQ-aware” (Hausvik, 2017). Furthermore, commonly known waste activities
have been identified in healthcare as a consequence of poor information quality. These are such as the unnecessary repetition of a surgery, delayed performance of a task, excessive movements, wasted time in communications, and the search for additional information or items (Al-Hakim, 2014).
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occurred from inpatient to outpatient surgeries, as less patients are required to be hospitalized and stay overnight after having surgery (Emery & Paraiso, 2015). The magnitude of change has been substantial in Sweden, where the number of outpatient surgeries has between 2005 and 2015 increased by approximately 113%, see Figure 1 (Socialstyrelsen, 2017).
Figure 1 – The development of outpatient surgeries between 2005 and 2015 (Socialstyrelsen, 2017).
Surgery is considered as the high cost and revenue service of hospitals. Hence, optimizing the effectiveness and efficiency of the operating theatre is believed to be essential (Su & Shen, 2010). The movement from inpatient to outpatient surgeries has allowed for major costs savings, as surgical procedures are performed in a less resource intensive environment (Emery & Paraiso, 2015). Based on a study conducted by Tiainen and Lindelius (2016), the increase of outpatient surgeries in Sweden has saved approximately 14% of the total costs associated with surgeries. In addition to this, 738 hospital beds have been released within the surgical functions from 2005 to 2013, which is a 9% decrease. The shift to performing more outpatient surgeries was in turn responsible for 80 of these hospital beds, which corresponds to around 11% of the total release of hospital beds (Tiainen & Lindelius, 2016).
Due to the great increase and potential of outpatient surgeries, it is important to improve the process performance to meet both current and future demand of outpatient surgeries, and to continue to improve the efficiency of healthcare (Tiainen & Lindelius, 2016).
1.2 Problematization
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is highly time and resource consuming, where a great need for process improvements has been experienced, ensuring patient safety as well as minimizing unnecessary expenses (Töpfer et al., 2017).
The outpatient surgery at the women’s department is mainly constituted by one operating theatre which holds around 7-10 surgeries each day. The types of conducted surgeries vary greatly, where hysteroscopies, conizations, abortions, and sterilizations are some of the most commonly performed surgeries. This implies a great variation in surgical preparations as well in terms of tools, equipment, and local anesthesia for the different types of surgeries. Consequently, the work inside the operating theatre in between surgeries is quite intensive due to the number of surgeries that are required to be performed each day and the large differences in preparations of the various surgeries. Thus, disruptions of the workflow inside the operating theatre often occurs, which in turn causes delays and generates waste in terms of rework and discard of unused disposable items. Therefore, the outpatient surgery at the women’s ward is in great need of increasing the efficiency of its processes. This is to advance the working environment and economical effects as well as to meet the continuously growing demand of outpatient surgeries.
1.3 Purpose and research questions
The purpose of this study is to investigate how the process performance of outpatient surgeries can be improved by managing information quality. Thus, the aim is to identify improvement areas within the quality of the information which control the process performance of the outpatient surgery. Given the purpose and aim of this study, the two following research questions are formulated:
RQ1: What are the implications of poor information quality on waste in the outpatient
surgery?
RQ2: Which factors influence the information quality in the outpatient surgery
negatively?
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1.4 Thesis Outline
The outline of this thesis is presented in Figure 2 below.
Figure 2 – Thesis outline for the report.
Chapter 6 - Discussion
Presents the discussion of the findings, contribution of this study, as well as the limitations and potential future work.
Chapter 5 - Conclusion
Presents the conclusions based on the two research questions, and thus also the puspose of this study.
Chapter 4 - Analysis
Presents the empirical findings and analysis of the study based on the two research questions, thereby describing the outpatient surgery, the implications of information quality
on waste, and the factors influencing information quality.
Chapter 3 - Method
Describes the methodology used in this study, including the overall research approach, a detailed description of the literature review and case study, as well as the quality of
analysis.
Chapter 2 - Literature Review
Presents relevant theories and previous research in the field of healthcare, information quality, and waste.
Chapter 1 - Introduction
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2. Literature review
This chapter presents a review on literature, consisting of previous research and theories in the field of healthcare and outpatient surgery, information quality, and waste. These are in turn, together with the conducted empirical study, used as a basis for answering the two research questions of this study.
The literature review consists of three main parts: healthcare and outpatient surgeries,
information quality and waste. The combination of these three parts, together with the
conducted empirical study, will be used for analyzing the correlation of information quality and waste in the outpatient surgery, as well as for identifying how process performance of outpatient surgeries can be improved by managing information quality, see Area 1 in Figure 3.The first section of this chapter, Characteristics of Healthcare and Outpatient Surgery, presents an introduction to the context of this study. The section aims to provide an understanding of the characteristics of the context to, in the following sections, adapt the choice of theories and previous research for the specific context. This is followed by the section Information Quality that describes the different definitions and dimensions of the concept in different contexts, and also presents how information quality is applied in healthcare, symbolizing Area 2. Thereafter, the seven types of waste identified in lean are presented together with their corresponding translation in healthcare services in the section Waste in Healthcare, see Area 3. Finally, previous research on the influence of information quality on process performance and waste is presented in the section Implications of Information Quality, representing Area 4.
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2.1 Characteristics of Healthcare and Outpatient Surgery
The work in healthcare is very complex and dynamic (Buchbinder & Thompson, 2009). When comparing to a manufacturing context, the patients are considered as both products and customers which not only contributes to several characteristics that distinguish the healthcare setting for other more traditional industrial environments, but also makes these processes much more complex and dynamic (Wickramasinghe et al., 2014).
Every patient is unique. Although two patients seem to experience the same complaint, these might still be treated differently. The uniqueness of patients also appears during treatments, as one patient might respond differently to the same treatment in comparison to another, which in turn might result in unexpected complications. Patients do not only differ in physical attributes, but also in behavior. An example of this is the risk of patients cancelling a surgery or treatment (Gong, 2009). The work in healthcare is thus much complex, where every patient must receive an individual medical assessment, planning and treatment. The healthcare industry is therefore largely dependent on human involvement and thereby the knowledge and experience that the personnel possesses (Cabitza & Batini, 2016). This is a great difference from other industries where automatization is common and the human involvement is preferably minimized to the greatest extent as possible (Wickramasinghe et al., 2014).
The time required to perform a specific part of the process, also known as cycle time, often varies greatly in a healthcare context. This is mainly due to the the uniqueness of each patient which makes it almost impossible to predict the cycle time. The complexity of the setting also entails a difficulty in measuring performance of the healthcare personnel and in predicting the success of the treatment (Al-Hakim, 2006). Furthermore, waiting time, that in other industries often is considered to not create any value and aimed to be minimized, is in healthcare sometimes an essential activity. This can be seen, for example during surgery, where the anesthesia nurse and anesthetist, after performing their work in the beginning of the surgery, monitor the patient’s values during the surgery to ensure the safety and health of the patient (Gong, 2009).
The mentioned characteristics above apply for both patients having inpatient or outpatient surgeries. What distinguishes outpatient surgeries is that the treatment or surgery does not require the patient to be hospitalized and stay overnight, meaning that patients arrive and return home on the same day (Garduño-Chávez et al., 2016). The patients who are referred to outpatient surgery have previously been either at a general practitioner or a specialist doctor (Gong, 2009; Danderyds Sjukhus, 2017.a), which implies that there is a possibility that the patient has not met the operating physician until the day of surgery. Furthermore, the operating room staff (OR-staff) relies on provided information, together with their competence and previous experience, to fulfill their complex tasks (Cabitza & Batini, 2016).
2.2 Information Quality
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dimensions of information quality which varies depending on the context and the intended use of information (Lee et al., 2001). Thus, the following sections presents the different attempts on defining information quality and its dimensions, and lastly, concludes the definition and dimensions of information quality chosen for this study.
2.2.1 Defining Information Quality
Before defining information quality, three basic concepts are required to be defined - data, information, and quality. Accordingly to the Oxford English Dictionary (OED) (2017) information is defined as “facts provided or learned about something or someone” or “what is conveyed or represented by a particular arrangement or sequence of things”. Another general definition of information is provided by Belkin and Robertson (1997) who described information as “the structure of any text [data] which is capable of changing the image-structure of a recipient”. Here, structure simply is referred to as order and text is defined as a “collection of signs purposefully structured by a sender with intention of changing the image-structure of a recipient.” Moreover, Higgins (1999) follows the theoretic tradition of information by defining it as data with “recognizable patterns of meaning” which allows for uncertainty to be reduced for decision makers.
In contrast to previous general definitions, Taylor (1986) attempts to establish a more clear distinction between data, information, and knowledge. Thus, data is defined as a sequence of symbols, information as data with relations, and lastly knowledge as information that has been selected, analyzed, concluded, organized and stored for future possible use when informing or making decisions. Despite Taylor’s efforts on distinguishing data from information, where the view of information as data in context has been adopted by many (Wiig, 1993; Davenport, 1997; Lillrank, 2003), these two concepts are often used interchangeably (Baškarada, 2009). Consequently, what is considered as data by one person can be considered as information by another (Redman, 1992). Hence, in light of these definitions and for the purpose of this study, data is henceforward defined as a sequence of symbols and information as data in a context for which it is interpreted and/or used.
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be considered based on the context of healthcare and the characteristics and needs of the users in conjunction with outpatient surgeries.
2.2.2 Dimensions of Information Quality
Information quality is a multi-dimensional concept (Hausvik, 2017) and has been divided into different components that together constitute the quality of information. In a research conducted by Li et al. (2005), information quality is referred to as accuracy, adequacy, credibility and timeliness of the information. Other researchers such as DeLone and McLean do not mention adequacy or credibility but instead acknowledge the importance of relevancy as a dimension of information quality, while another researcher, McCormack, consider availability as an additional dimension (Zhou et al., 2013). Several other researchers such as Wand and Wang, Jarke and Vassiliou, Zmud and Goodhue, amongst others have also contributed with dimensions of information quality (Lee et al., 2001) and in total have more than 70 different dimensions been identified (Eppler, 2006) Furthermore, as mentioned in the previous section, information quality varies depending on the user’s need and context. Consequently, to analyze the information quality and answer the research questions, the dimensions are required to be adjusted and determined for the context of this study.
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Table 1 – Dimensions of information quality in healthcare.
Cabitza & Batini (2016)
Ratananingtyas et al. (2013)
Al-Hakim
(2014)
Accuracy Accuracy Accuracy
Currency (up-to date) Timely Timeliness
Completeness Completeness Completeness
Readability Clearly Ease of understanding
Usefulness Exactly Relevancy
Confidentiality (availability) Accessibility Accessibility/availability
Reliability Believability
Cost-effectiveness
Flexibility
Coherency
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Table 2 – Description of the dimensions of information quality chosen for outpatient surgery.
Dimension Description
Accuracy The information is correct.
Timeliness The information is up-to-date.
Completeness The information is sufficient and no other information is needed. Ease of understanding The information is easy to comprehend.
Relevancy The information is of relevance for the context.
Accessibility The information can quickly be retrievable and is easy to obtain. Believability The information is credible by the persons involved.
2.3 Wastes in healthcare
Waste can appear in many different contexts and shapes (Jylhä & Suvanto, 2015), and is mainly characterized as a non-value adding activity, process step or product feature (Daultini et al., 2015). Lean is a quality improvement philosophy that seeks to enhance customer value. This is achieved by either maximizing the value creation for customers at the same cost, or eliminating waste through the use of certain tools and techniques, thereby reducing the associated costs (Hines et al., 2004; de Koning et al., 2006). Although lean philosophy originated from the Toyota Production System (TPS) in the 1950s, it has been widely adopted in both manufacturing and service organizations ever since (Guimarães & Carvalho, 2012; Suárez-Barraza et al., 2012). However, in difference to production systems, service organizations pose great challenges due to the presence of customers (or patients, as it is in healthcare) in the system (Patwardhan & Patwardhan, 2008). Nevertheless, the adoption of lean in healthcare services has rapidly increased over the last decade (Burgess & Radnor, 2013), resulting in both tangible and intangible benefits such as reduced costs, increased quality, patient safety and efficiency (Jimmerson et al., 2005; D’Andreamatteo, et al., 2015), as well as improved patient and employee satisfaction (Fillingham, 2007).
There are seven types of waste identified in lean, namely transportation, inventory, motion,
waiting, overproduction, overprocessing and defect. Along with the adoption of lean
philosophy in healthcare services, the seven types of waste have been translated and adjusted to the context of healthcare. These are further described in the sections below.
Transportation involves all unnecessary movement of people, equipment, materials, tools, parts
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avoided, the negative impact of it can be reduced considerably by for instance having the preoperative area nearby the operating room (Al-Hakim, 2014).
Inventory includes excess of material and work-in-process, which constitutes a risk of hiding
problems or causing delays and excess transportation (Ohno, 1988; Liker & Meier, 2006). The equivalents for inventory in healthcare are such as unused storerooms with excess stock, delayed discharge of patients or long waiting lists for getting medical assessment, special treatment, or surgery (NHS, 2007; Al-Hakim, 2014).
In similarity to transportation, motion involves the movement of people or equipment that is not needed to perform the processing, such as reaching or searching for materials, tools or information (Ohno, 1988; Liker & Meier, 2006). Examples of unnecessary movements in a healthcare context are such as medical staff searching for essential papers (e.g. drug sheets) or materials. Furthermore, extra physical efforts and movements required for performing everyday tasks such as not storing syringes and needles within a close range, or lacking basic equipment in each one of the examination rooms are all factors that contribute to excessive movements (NHS, 2007; Al-Hakim, 2014).
Waiting refers to idle time of equipment or employees caused by processing delays or resource
bottlenecks (Ohno, 1988; Liker & Meier, 2006). In healthcare, the delay in performing an activity is often caused by the wait for patients, trolleys to move patients, medical staff, test results, prescriptions or medicines (NHS, 2007; Al-Hakim, 2014). Furthermore, the waiting for doctors to discharge their patients also cause additional waste as increase in inventory (Al-Hakim, 2014).
Overproduction occurs when items are produced in higher quantities than needed or ahead of
demand, which in turn generates additional waste such as inventory (Ohno, 1988; Liker & Meier, 2006). Identified sources of overproduction in healthcare are such as requesting unnecessary and excessive tests (e.g. repeating x-rays or medical tests), reserving examination rooms and extra beds in discharge room ‘just in case’ as well as not switching off lights or air conditioning after operating hours (NHS, 2007; Al-Hakim, 2014).
Overprocessing, on the other hand, occurs when items are inappropriately, unnecessarily or
excessively processed, which also may cause additional waste in terms of unnecessary motion or produced defects (Ohno, 1988; Liker & Meier, 2006). Thus, overprocessing is the unnecessary repetition of an action. Consequently, actions such as repeatedly recounting instruments, requesting for patients’ details and clerking of patients are considered as waste in healthcare. These may in turn also cause an increase of inventory as information is duplicated and irrelevant information is stored (NHS, 2007; Al-Hakim, 2014).
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drug reactions, repeated testing as a consequence of incorrect or inadequate provided information (NHS, 2007; Al-Hakim, 2014).
The above examples of waste in healthcare provided by NHS (2007) are summarized in the table below.
Table 3 - Examples of waste in healthcare services.
Waste Healthcare service examples (NHS, 2007)
Transportation • Staff walking to the other end of a ward to pick up notes
• Central equipment stores for commonly used items instead of items located where they are used
Inventory • Excess stock in storerooms that is not being used • Patients waiting to be discharged
• Waiting lists
Motion • Unnecessary staff movement looking for paperwork, e.g. drug sheets not put back in the correct place
• Storing syringes and needles at opposite ends of the room • Not having basic equipment in every examination room Waiting • Waiting for
o Patients, theatre staff, results, prescriptions and medicines o Doctors to discharge patients
Overproduction • Requesting unnecessary tests from pathology • Keeping investigation slots 'just in case' Overprocessing • Duplication of information
• Asking for patients’ details several times • Repeated clerking of patients
Defects • Readmission because of failed discharge • Adverse drug reactions
• Repeating tests because correct information was not provided
2.4 Implications of Information Quality
The quality of information is considered to be of great importance for the competitive advantage of organizations (Abdullah & Azim, 2015). Lacking information quality has resulted in major implications in terms of process performance and creation of waste, which will be further discussed in following sections.
2.4.1 Information Quality and Process Performance
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& Helfert, 2004; Fisher & Kingma, 2001). For instance, in production processes of manufacturing organizations, if products are not delivered on schedule and do not meet the customer needs, the customers will most likely be unsatisfied which in turn will damage the organization’s business. The same goes for information management processes. If the information is not up-to-date and does not meet the user needs, the information cannot be considered as relevant, thus leaving the users unsatisfied and will most likely lead to systematic errors and damage the organizational performance (Clikeman, 1999).
According to previous research, an adoption of quality improvement initiatives has proven to reduce costs while increasing productivity, thereby resulting in an increased profitability (Wisner & Eakins, 1994; Hausvik, 2017). Poor information quality, on the other hand, has indicated an adverse effect on the competitiveness of an organization (Redman, 1992). A study based on a literature review of 71 research articles shows that information quality has a direct and exclusive impact on process performance (Hausvik, 2017), where the lack of quality has resulted in errors and adverse events in healthcare processes (Clark et al., 2013). A connection between the quality of information and the performance of surgery processes has also been found, where variations in information accuracy, timeliness and completeness have affected the operating time, cost of operation process, capacity utilization, and lastly, length of waiting queues (Su & Shen, 2010).
Redman (1998) identified and structured the different negative impacts that lacking information quality might have on an organization. These are presented in three business layers - operational, tactical, and strategic, see Figure 4 below. Although all three business levels are of great importance to understand the true extent and impact of poor information quality, this study will mainly focus on the operational level.
Figure 4 – The impact of poor information quality on each of the three business layers in organizations (Redman, 1998).
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(Redman, 1998). Firstly, the dissatisfaction among customers is believed to arise due to unmet expectations in terms of accuracy, completeness, relevancy, timeliness and such (Redman, 1998; Wang et al., 1998). The main driver of the dissatisfaction of employees, on the other hand, is believed to be the lack of fulfilling the user’s needs which are based on their professional duties (Stvilia, et al. 2007; Taylor, 1991), and the disappointment of not meeting the customers’ expectations (Redman, 1998). Lastly, the operational costs arise not only due to operational inefficiencies, but also due to resources being spent on identifying and correcting errors (Redman, 1998; Eppler & Helfert, 2004).
2.4.2 Information Quality and Waste
Only a few previous research has explored the implications of poor information quality on the seven types of identified waste. A study conducted by Jylhä and Suvanto (2015), consisting 130 interviews and workshops with four case organizations and their customers, investigated how the service processes in facility management were influenced by poor information quality. The results of this study confirmed the hypothesis of that poor information quality generates a great amount of waste, where three major impacts were found based on the cross-case analysis. Firstly, a lot of time was wasted searching for information due to two reasons. One, the low accessibility caused by either non-standardized distribution channels or a flood of information which decreases the relevancy of information provided and obstructs the use of necessary information. Two, the incompleteness of the information provided which in turn also requires the search for needed information. Thus, the low accessibility and relevancy and the incompleteness of information lead to employees being required to spend time searching for necessary information, thereby generating waste in terms of motion as it causes unnecessary staff movement. (Jylhä & Suvanto, 2015)
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Lastly, the study showed that poor information quality also resulted in a loss of potential, where the lost potential is referred to as information that has been invested in, but eventually not used. Based on the conducted cross-case analysis, three main reasons were identified for the loss of potential. One, although time and effort were invested to produce the information, it was not delivered on time (low timeliness) and could therefore not be used to the fullest, resulting in an overproduction of information. Two, great volumes of information were distributed among the employees, including both relevant and irrelevant information. Due to the excessive amount of information, irrelevant information prevented relevant information to be seen and used, thereby leading to a loss of potential. Three, information was sometimes deliberately ignored as it was not considered to be in the right form. Consequently, low relevancy and timeliness caused the waste types overproduction and inventory, as redundant and unnecessary information was produced and stored. (Jylhä & Suvanto, 2015)
Based on the case study evidence presented above, Jylhä and Suvanto (2015) argue that poor information quality has a direct impact on waste activities. Conclusively, quality of information is required to be improved to minimize waste. An empirical study conducted by Al-Hakim (2014) investigated the impact of information quality on waste activities in emergency departments due to the lack of previous empirical evidence on the relationship between quality of information and disruptions. The research consisted of four months of observations at two Chinese emergency departments, including activities of 19 emergency doctors and 28 nurses. As a result, the study presented strong empirical evidence on the implications of poor information quality on disruptions and waste activities caused in emergency departments. While approximately 16% of the observed emergency doctors’ time was spent on waste activities as a result of poor information quality, the corresponding figure for emergency nurses’ time was more than 29%. Among generated waste, roughly 42% was caused by the lack of availability and timeliness of information. Furthermore, the incompleteness and irrelevance of information caused about 15.5% respectively 16% of the generated waste. An additional 11% of the total waste occurred in form of prolonged emergency services, caused by inaccuracy of information. Lastly, with less than 5% effect on identified waste, the dimensions ‘ease of understanding’ and ‘believability’ of information were not considered to be an issue.
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3. Method
The following chapter describes the methodology used in this study. Initially, the overall research approach of the study is presented followed by a description of the literature review and case study. Lastly, the quality of analysis is presented.
3.1 Research Approach
The purpose of this study is to investigate how the process performance of outpatient surgeries can be improved by managing information quality. Thus, the aim is to identify improvement areas within the quality of the information which control the process performance of the outpatient surgery.
As the study intends to investigate a phenomenon that is unique for a specific real-life context, a case study is considered to be appropriate and therefore chosen to be pursued (Collis & Hussey, 2014). Yin (2009) emphasizes the distinction between case studies and other research methods by defining case studies to be of specific importance for when the boundaries between phenomenon and context are not clearly evident. This is believed to support the choice of research method based on the distinctive study characteristics. By conducting a case study, phenomenon in complex human and social systems can be observed and analyzed as a single, integrated whole. This is enabled by the holistic approach of case studies which allow for detailed descriptions of situations and events to be produced, as well as provides in-depth understanding of interactions and elements involved (Gagnon, 2010). However, there are also several challenges related to case research, such as being time consuming, requiring skilled interviewers, and causing difficulties in drawing generalizable conclusion from a restricted number of cases and establishing rigorous research. Nevertheless, it is the same set of characteristics that allow for the in-depth analysis and understanding of a specific phenomenon (Voss et al., 2002).
The number of case studies is also believed to have an impact on the degree of experienced challenges and opportunities of case research. While fewer case studies are to be preferred for greater in-depth observations for a limited set of available resources, these also entails greater risks for misjudgments of single occasional events and exaggeration of collected data (Voss et al., 2002). Consequently, the generalizability of conclusions is aggravated by single case studies (Leonard-Barton, 1990). Conducting multiple case studies have the potential of reducing these risks by comparing events and data across cases, however, at the expense of reducing the depth of the study (Voss et al., 2002). Based on the purpose and aim of this study, a more in-depth research is to be preferred and thereby a single case study chosen to be pursued.
3.2 Literature Review
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chosen field of study, the literature review also facilitated the positioning of the study in relation to previous research (Collis & Hussey, 2014).
The literature review was conducted throughout the research process. At first, a divergent approach was maintained by reviewing and evaluating a broad field of knowledge. The literature mainly consisted of books, articles and reports. These were in turn systematically summarized, where key findings were extracted from each and categorized accordingly to themes to facilitate the review process and following analysis of the literature (Collis & Hussey, 2014). Afterwards, when a broader understanding of existing literature and a deeper understanding of the phenomenon and its context were obtained, a more convergent approach was pursued. The literature review was thereby narrowed down incrementally along the research process (Blomkvist & Hallin, 2015).
When conducting the literature review, similarities and differences among existing literature and in relation to the study findings were analyzed. Tying together similar literature and findings, as well as addressing literature that conflicts with the study findings induced a more creative thinking and deeper insights. This in turn increased both the validity and quality of the study findings (Voss et al., 2002).
Books, articles and reports were obtained from the search engines Google Scholar and KTHB Primo which gave access to content from publishers such as Emerald Insight, Wiley Online Library, Springer Link, Elsevier and SAGE. The search terms information quality, process
performance, waste, lean, healthcare, hospital, outpatient surgery and management were all
used in different combinations, both in Swedish and English, when searching for relevant literature.
3.3 Case Study
The case study was pursued in parallel to the literature review to collect empirical data. The case study included the five main stages recommended by Collis and Hussey (2014). The stages,
selecting the case, preliminary investigations, data collection, data analysis and writing the report are described in detail in the upcoming sections.
3.3.1 Selecting the Case
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Since the case was noticed CIF and not selected based on the study, there is a possibility that this case is not the most suitable for the purpose of this study. However, it is considered to be appropriate as it covers the research area and as the problem area is thoroughly chosen by the multidisciplinary team (Collis & Hussey, 2014). Moreover, since the personnel at the hospital have experienced the problem it facilitated the gathering of data as they were willing to dedicate their time, which also is important to considerer (Voss et al., 2002). Furthermore, the operation unit is a part of one of the largest public hospitals in Sweden, meaning it has similar practices and approaches as many other hospitals within the public sector in Sweden. Thus, the findings of this project could potentially be applicable to other public hospitals in Sweden as well and make a great contribution.
3.3.2 Preliminary Investigations
The study was initiated through a pre-study of the operation unit at the women’s department, Danderyd’s University Hospital. The preliminary investigations were conducted to gain insights and a deeper understanding of the context of the study (Collis & Hussey, 2014). It mainly consisted of multiple observations, informal discussions with personnel at Danderyd’s University Hospital to understand the current situation at the operation unit. This in turn enabled problems with focus on information quality and waste to be surfaced, analyzed and evaluated based on their critical nature and impact on the overall flow within the operation unit. Additionally, the literature study was conducted in parallel to the initial empirical data gathering. This was to relate possible theories to the identified problem areas.
The information gathered from the preliminary investigations and literature review was the foundation of the problematization which in turn was the basis for the purpose and research questions. They were formulated in a discussion with the supervisor from both Danderyd’s University Hospital and KTH.
3.3.3 Data Collection
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Figure 5 – Triangulation, using different methods and sources for gathering data to increase the reliability and validity of the study.
The work in healthcare is dynamic, where unpredictable events resulting in a decreased process performance occur. This could for instance be complications during surgery or other delays and issues concerning the patients. However, only information regarding events that could be predicted are included and investigated in this study. Thus, other events damaging process performance will be delimited from the study during the observations, interviews, survey and document review.
Observations
There are different degrees of participation in an observation. The researcher can be completely participating in the activities or not even positioned in the same location and thereby a complete observant. There are both advantages and disadvantages with all different levels of participation. For this study, the most suitable levels of participation were to conduct observations as both as-observant and observant-as-participant. In the participant-as-observant a more participant role was taken which gave the opportunity to ask questions about the observed situation, enabling a deeper understanding of the events which was appropriate for the chosen purpose (Gerrish & Lacey, 2010; Bryman, 2004). However, these types of observations have a risk of affecting the events and thereby decreasing the validity. Therefore, this type of observation was conducted in combination with observations where an observant-as-participant role was taken interfere of the situation was avoided. Consequently, both a high level of understanding of the situation and an accurate perception of the situation were thereby obtained (Gerrish & Lacey, 2010).
During the empirical data gathering, 53 surgeries were observed. The observations consisted not only of observing surgeries, but also observations and discussions in the operation unit and lunch room and in total were 344 hours spent at Danderyd’s University Hospital. During the
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observations, the influencing factors of information quality and the occurring waste were examined and analyzed, which was later used to answer both research questions.
Notes were taken during all observations, where the events and reflections were transcribed. The notes were taken separately and thereafter compared and discussed to cover as must as possible of the event and to reduce the risk of misinterpretations and thereby increased validity of the findings from the observations.
Due to the sensitive nature of the information managed in a hospital, a confidentially agreement was signed before any observations. This agreement implied that no patient information should be discussed or shared and stay confidential. This agreement had no negative impact on the study since patient information was not a part of this study. Instead, it enabled participation during the entire operating flow and thereby contributed to a better understanding that was useful for the study.
Interviews
To collect the empirical data needed to answer the research questions, 16 semi-structured interviews were in total conducted. During a semi-structured interview, the questions are predetermined but the researchers still have the opportunity to ask supplementary questions (Collis & Hussey, 2014). This enabled a deeper understanding of the answers and of the subject which was considered to be suitable with the purpose of this study.
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Table 4 – Summary of the conducted interviews.
Interviewee Main work tasks Duration Answering
Assistant Nurse 1 Prepare operating theatre, assist during surgery with tools and equipment and clean.
40 min RQ1
Assistant Nurse 2 Prepare operating theatre, assist during surgery with tools and equipment and clean.
1h 15 min RQ1 Assistant Nurse 3 Prepare operating theatre, assist during
surgery with tools and equipment and clean.
30 min RQ1
Assistant Nurse 4 Prepare operating theatre, assist during surgery with tools and equipment and clean.
25 min RQ1
Surgical Nurse 1 Prepare operating theatre, assist surgeon during surgery and, after surgery, handle the
medicinal preparations and tools.
30 min RQ1
Surgical Nurse 2 Prepare operating theatre, assist surgeon during surgery and, after surgery, handle the
medicinal preparations and tools.
25 min RQ1
Surgical Nurse 3 Prepare operating theatre, assist surgeon during surgery and, after surgery, handle the
medicinal preparations and tools.
40 min RQ1
Surgical Nurse 4 Prepare operating theatre, assist surgeon during surgery and, after surgery, handle the
medicinal preparations and tools.
40 min RQ1
Surgical Nurse 5 Prepare operating theatre, assist surgeon during surgery and, after surgery, handle the
medicinal preparations and tools.
25 min RQ1
Surgeon 1 Read patient record and/or consultation report, talk to the patient and plan and
perform the surgery.
1h 10 min RQ2 Surgeon 2 Read patient record and/or consultation
report, talk to the patient and plan and perform the surgery.
30 min RQ2
Surgeon 3 Read patient record and/or consultation report, talk to the patient and plan and
perform the surgery.
55 min RQ2
Surgeon 4 Read patient record and/or consultation report, talk to the patient and plan and
perform the surgery.
40 min RQ2
Surgeon 5 Read patient record and/or consultation report, talk to the patient and plan and
perform the surgery
40 min RQ2
Surgeon 6 Read patient record and/or consultation report, talk to the patient and plan and
perform the surgery.
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Surgeon 7 Read patient record and/or consultation report, talk to the patient and plan and
perform the surgery.
30 min RQ2
The purpose of the interviews, together with the questions were e-mailed to the interviewees in advance. This implied that the interviewees could think about the answers and came prepared (Voss et al., 2002). Additionally, this contributed for interviewees to feel more comfortable. According to Easterby-Smith et al. (2008), feeling comfortable and to trust the interviewing is very important to obtain the desired answers. The interviews were conducted face-to-face in a familiar environment for the interviewees which also contributed to them feeling comfortable (Collis & Hussey, 2014). Furthermore, the ethical guidelines recommended by Collis and Hussey (2014) were followed and all interviewees were informed that they would be kept anonymous in the report and how their responses would contribute to the research.
There were two who interviewed which increased the confidence of the findings (Voss et al., 2002; Collis & Hussey, 2014). One had the responsibility of asking the questions whilst the other took notes and asked supplementary questions. After obtaining approval from the interviewees, all interviews were recorded. This enabled the possibility to listen to parts of interview once more if there were any uncertainties. However, this is very time consuming and was avoided if possible.
As recommended by Voss et al. (2002), the funnel model was used and the interviews started with broad questions but were them narrowed down and became more detailed. A disadvantage with semi-structured interviews is that since the answers could vary from each interviewee, they could be difficult to compare (Collis & Hussey, 2014). Thus, a survey consisting of structured questions was conducted to complement the insights obtained from the interviews, and enable comparisons between the answers gathered from the different interviewees. However, to evaluate which structured questions that were most suitable for the survey, and to obtain qualitative comments and insights around the structured questions, these were also included during the interviews in combination with semi-structured questions. During the interviews, qualitative answers in conjunction to quantitative data was initially obtained to ensure the appropriateness of the structured questions, which in turn increased their validity. Furthermore, besides enabling comparisons between different answers, the quantitative data from the interviews also reduced the risk of biased interpretations of the answers while still allowing qualitative reflections and explanations regarding the interviewees choices.
Survey
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and discussion. Furthermore, the survey was conducted among the surgical staff, which based on the interviews were not aware of the quality dimension timeliness. Additionally, the accessibility of the information in Orbit, the computer system managing the planning and scheduling of surgeries, was evaluated during the observations. Thus, this dimensions did not need further investigation of validation through the survey and was therefore also excluded. Finally, all questions regarding local anesthesia were also excluded since it became clear during the interviews that this information was never included in Orbit and could therefore not be evaluated in a survey.
The survey was answered by 16 of the surgical staff. This in turn increases the overall reliability of the answers obtained from the structured questions during both the interviews and the survey among the surgical staff. However, since the survey was answered by 16 out of 23 of the surgical staff, the approximately 70% response rate is not sufficient to state the opinions from all surgical staff working with outpatient surgery at the case company’s women’s department but gave an indication (Arvidsson, 2016).
Document Review
The surgical staff at the case company were provided with a printout from their computer system, Orbit. The purpose of this printout was to provide the surgical staff with the information needed to prepare the operating theatre. This document, was studied to evaluate what information that was provided, and its quality.
3.3.4 Data Analysis
The data analysis was conducted iteratively and in parallel to the data collection. There are mainly two different approaches of analyzing data, namely within-case analysis or cross-case analysis (Collis & Hussey, 2014). Since this study only consists of a single case, a within-case analysis was pursued to identify possible patterns in the gathered data. The data analysis was in turn conducted accordingly to a three-step process; data condensation, data display, and conclusion drawing and verification (Miles et al., 2014).
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Secondly, after the condensation of data, the second part of the data analysis process follows, namely the display of data. Data display refers to the visualization of data in terms of graphs, charts and such. The visualization of data facilitates the information-processing and increases the robustness of qualitative analysis by assembling organized information into a clear and accessible form. Based on the displayed data, either justified conclusions can be drawn or a foundation for further analysis can be established (Miles et al., 2014). For instance, results from the survey were organized and visualized in charts by using Microsoft Excel to provide a structured and clear foundation to draw conclusions from and base further analysis on, see Appendix B.
Lastly, the third activity of data analysis consists of drawing and verifying conclusions. This is realized through a continuous process of coding, storing, and retrieving field notes which gradually allows for generalizations to be developed (Miles et al., 2014). Hence, empirical material was throughout this study reviewed, coded, sorted, stored and retrieved. Once retrieved, these were compared to other empirical findings and also to existing literature to find supporting or conflicting arguments. This in turn allowed generalizations to be developed iteratively and research questions to be answered.
3.3.5 Writing the Report
The report was structured according to the recommendations by Blomqvist and Hallin (2015) with some minor adjustment. The writing of the report was an interactive and continuous process throughout the project. The research design for this project, including the five stages of the case study and literature review, which can be seen in Fel! Det går inrte att hitta någon
referenskälla.6.
Figure 6 – The study research design.
3.4 Research Quality
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four criteria; internal validity, construct validity, external validity, and reliability. Each of these are discussed in detail in the sections below, followed by a summary accordingly to Gibbert et al.’s (2008) framework.
3.4.1 Internal Validity
The internal validity of a study refers to the data analysis phase and depends on the extent to which causal relationships can be established between variables and results. Thus, it requires researchers to provide logical arguments and reasoning to defend (Gibbert & Wicki, 2008; Voss et al., 2002). There are three measures for enhancing internal validity; clear research
framework, pattern matching, and theory triangulation.
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healthcare were adopted when analyzing the information quality in the outpatient surgery. By doing so, the analysis of the information quality in the outpatient surgery could be based on suitable dimensions, as these were supported by several perspectives, thereby increasing the internal validity of the study. However, as the different adopted perspectives of information quality dimensions in healthcare were almost identical with the exception of one or two single differences, the study might be criticized for restrictively using theory triangulation. Although, it might also support the appropriateness of the dimensions chosen and analyzed for this specific context.
3.4.2 Construct Validity
Construct validity refers to the extent of how accurate the study investigates what it aims to investigate and how well it reflects the reality. Obtaining construct validity should be considered when gathering data, where the two approaches described by Gibbert et al. (2008) have been used in this study. First, establishing a chain of evidence was used to ensure construct validity. This was done through providing the reader with a description of the process from the initial research questions to the final conclusions.
Second, triangulation has also been used to further enhance the construct validity of this study. There are different types of triangulation which contribute to a higher construct validity. In this study, three different triangulations were used, namely data triangulation, methodology
triangulation, and investigator triangulation. Data triangulation was used by collecting data
from several different sources. This was achieved by for instance conducting interviews with several different interviewees. Methodology triangulation, on the other hand, refers to data that are collected through different methodologies such as interviews, observations and internal documentation. Lastly, during the observations, investigator triangulation was used as notes were taken independently which enabled different investigators to study the same situation (Easterby-Smith et al., 2008). Consequently, a chain of evidence was established and triangulation has been used throughout the study which contributed to a high construct validity.
3.4.3 External Validity
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3.4.4 Reliability
A study is considered to have a high reliability if it can be repeated, with the same methodology, and reach the same findings (Collis & Hussey, 2014). According to Gilbert et al. (2008), the most important components in achieving reliability is transparency and replication. The transparency of this study is considered to be high due to the detailed method chapter and attached interview questions. This allows other researchers to repeat the method and thereby contributing to a higher reliability. The replication of the study is also considered to be high since the documentation from all observations and interviews were saved in a case study database which also facilitates for the study to be replicated. However, due to ethical reasons and legislations in healthcare, this is not attached in this report.
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3.4.5 Summary
The study has used several different approaches to obtain a high quality and rigorousness. These are summarized in Table 5, seen below.
Table 5 – Summary of the approaches to obtain high quality and rigorousness.
Internal validity Construct validity External validity Reliability
A comparative analysis conducted between previous research and the empirical findings. Theory triangulation by adopting multiple perspectives of information quality dimensions. However, no clear research framework established for
investigating the causal relationship between different variables, as this was not intended to be investigated.
Establish a chain of evidence.
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4. Results and Analysis
The following chapter presents the results and analysis of this study, and is divided into three parts. The first part describes the outpatient surgery at the women’s ward at Danderyd’s University Hospital, while the second and third part present the results and analysis of RQ1 and RQ2 respectively.
4.1 The Outpatient Surgery
In this section, the operation unit at the women’s department at Danderyd’s University Hospital is presented. It also gives a work description for the OR-staff and the information provided in Orbit.
During the time spent at the women’s department at Danderyd’s University Hospital, the staff performed between seven and ten outpatient surgeries on an average day. The surgeries had varying durations, which resulted in the different number of surgeries performed each day. Commonly occurring surgeries were such as hysteroscopies, conizations, abortions and sterilizations. All outpatient surgeries were normally performed in operating theatre six, see Figure 7. This operating theatre was one of the smaller ones, thus a lot of the equipment and tools used during the outpatient surgeries were not permanently placed in adjacent to, or in, the operating theatre itself, but stored in the storage room for central equipment. There was also a separated storage for anesthesia where the staff retrieved the local anesthesia needed for the surgeries. As seen in the figure, there were other operating theatres at the department as well and to maintain a manageable overview of the personnel and surgeries, a board was kept in the hallway with the operation schedule.
Figure 7 – The outpatient surgery at the women’s department at Danderyd’s University Hospital.
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patient record and/or consultation report, talk to the patient and plan the surgery. Once the surgery was performed, the surgeon dictated, wrote referrals and prescribed medication. The surgical staff, constituted by the assistant nurse and the surgical nurse, prepared the operating theatre for surgery with the necessary equipment, tools and local anesthesia. During the surgery, the surgical nurse assisted the surgeon whilst the assistant nurse provided tools, controlled the equipment, retrieved additional tools or equipment and performed other necessities. After the surgery the surgical staff were responsible of cleaning the operating theatre and handling the medicinal preparations and tools that had been used. The anesthesia nurse and anesthetist were responsible for monitoring the health of the patient during the surgery and to ensure that a safe narcosis and sedation were performed.
31 Planerad operationssal Patient Planerad tid Operationskort Planerad operatör Planerad varaktighet Vårdande enhet
Preliminära åtgärder Info till Operations-personal Info till Anestesi KK Sal 6 56664 XX 8.15 Hysteroskopi - Bettochi (kk)
XX 00:30 Gyn mott *LGA22 - Hysteroskopisk sterilisering Kommer 07:30 KK Sal 6 56664 XX 9.15 Hysteroskopi - Resektion (kk) XX 00:30 Gyn mott *LCB25 – Hysteroskopi med extirpation av förändring Kommer 07:30 KK Sal 6 56664 XX 10.15 Hysteroskopi - Resektion (kk) XX 00:30 Gyn mott *LCB25 – Hysteroskopi med extirpation av förändring, TLC00 Kommer 08:30 KK Sal 6 56664 XX 11.30 Konisering - slynga (kk)
XX 00:15 Gyn mott *LDC03 Konisation med diatermi eller laser, LDA10 Abrasio av cervix uteri Kommer 09:00 KK Sal 6 56664 XX 13.00 Konisering - slynga (kk)
XX 00:15 Gyn mott *LDA10 Abrasio av cervix uteri, LDC03 Konisering med diatremi eller laser
Kommer 12:30 KK Sal 6 56664 XX 13.40 Sen spontanabort > v 12 (kk)
XX 00:10 Gyn mott *MBA00 - Exeres med
vakuumaspiration vid missfall eller efter förlossning Kommer 12:30 KK Sal 6 56664 XX 14.15 Tidig abort < v 12 (kk)
XX 00:07 Gyn mott *LCH00 - Exeres med vakuumaspiration Kommer 13:00 KK Sal 6 56664 XX 15.00 Tidig abort < v 12 (kk)
XX 00:07 Gyn mott *LCH00 - Exeres med
vakuumaspiration
Kommer 13:30
Figure 8 – An example of how the printout from Orbit typically looked like.
4.2 Implications of Information Quality on Waste
Based on the conducted empirical study, poor information quality was identified across all dimensions of quality. As a result, six of seven types of waste were identified in the outpatient surgery, namely transportation, motion, waiting, overproduction, overprocessing, and defects, whereas inventory was not found in this study. The absence of inventory might be explained with the delimitation of this study from events outside of, and not in connection to, the surgical theatre or because this waste did not occur. The implications of poor information quality on the identified waste activities will be presented in the following sections, thereby answering the first research question: What are the implications of information quality on waste in the
outpatient surgery?
4.2.1 Transportation
